Level One Nursing Facility Pre-Admission Screening for ...

1 Level One Nursing Facility Pre-Admission Screening for Mental Illness/. Intellectual Disability or Related Condition DHSS/COMRU. October 2021. Key Points The new process is now automated the link to complete the application will be located on COMRU's webpage: The Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition ( Level One Form) replaces the current DA 124 C form. This new application will be required for any individual seeking admission into a Medicaid certified bed in a Nursing Facility on or after October 31, 2021. The automated system will give the submitter a Return Code that is unique to each individual application. Please ensure the submitter writes down this code as it will be utilized throughout the process. 2. Section A. Individual Identifying Information 3. Individual's First and Last Name This should be the individual's legal name Suffix Examples include: Sr.

2 , Jr., or I, II, III . DCN (aka Medicaid Number). This is an eight digit number If the individual has not yet applied for Medicaid, this field should be left blank. Date of Birth This is entered in a mm-dd-yyyy format SSN Number Dashes must be entered between numbers XXX- XX-XXXX . Occupation This would be the occupation prior to the individual becoming disabled or retired If the individual never worked indicate never worked . 4. Section B. Individual's Contact Information 5. Previous Residence Type What type of setting was the Individual residing prior to this admission ? There is a drop down menu with the following options: Home / Facility Residence RCF (Residential Care Facility ). ICF (Intermediate Care Facility ). SNF (Skilled Nursing Facility ). ALF (Assisted Living Facility ). ICF-IID (Intermediate Care Facility for Individuals with Intellectual Disability). DMH Group Home / Individualized Supported Living DMH Psychiatric Hospital and Facilities Homeless / Shelter Incarcerated Provide Address of the Previous Residence Type 6.

3 Legal Guardian or Designated Contact Person Information If None is marked, the requested fields for the Legal/Guardian or Designated Contact information will disappear If the individual has a Legal Guardian or Designated Contact Person, please provide the requested information. This email will be used as the primary mode of providing letters and reports to the legal guardian. These records will be sent via an encrypted email. The email address is a required field on the application. 7. Section C. Referring Individual Completing Application This is the identifying information of the person completing the application prior to the physician's signature. 8. Section D. Level One Screening Criteria for Serious Mental Illness Please provide the signs and symptoms that the individual is displaying. Diagnoses are not accepted. 9. Section D. Level One Screening Criteria for Serious Mental Illness Please refer to the Physician's orders, History and Physical, and other supporting documentation to ensure that all the individual diagnoses are indicated on the application.

4 The submitter is able to mark more than one diagnosis. If the diagnosis is not listed, mark the Other Mental Disorder in the DSM box and list the diagnosis in the box. Please list only Major Mental Illness diagnoses. A Level 2 Screening is not automatically indicated if an individual has a Major Mental Illness diagnosis. 10. Section D. Level One Screening Criteria for Serious Mental Illness The submitter must choose at least one of the four categories. The submitter can choose more than 1 of the 3 categories (Interpersonal Functioning, Adaptation to Change and Concentration/Persistence and Pace) if applicable. 11. Adaptation to Change: Requires intervention by mental health or judicial system Is the individual currently receiving services in the community through Comprehensive Psychiatric Services (CPS DMH)? If the individual is receiving services, this category would be marked.

5 A Level 2 Screening would be indicated if any of the three categories are marked and Dementia is not the primary mental illness diagnosis 12. Section D. Level One Screening Criteria for Serious Mental Illness 13. Section D. Level One Screening Criteria for Serious Mental Illness If treatment history for the past two years is unknown or treatment was unavailable but otherwise appropriate to consider the individual is positive for serious mental illness. Examples might include (not an exclusive list): The individual went to the hospital and no psychiatric beds were available so the individual was not admitted to the psychiatric unit even though the client was having an episode. Instead, the individual stabilized on the medical floor. The Facility does not know whether or not the individual has had an inpatient stay due to the individual being a poor historian. A Level 2 Screening would be indicated if this question is marked Yes and Dementia is not the primary mental illness diagnosis 14.

6 Section D. Level One Screening Criteria for Serious Mental Illness Must be a documented diagnosis of current substance use or history of substance abuse A Level 2 Screening is not automatically indicated if an individual has a substance related disorder 15. Section D. Level One Screening Criteria for Serious Mental Illness If the individual does not have a diagnosis of Major Neurocognitive Disorder (MNCD). the additional questions in this section will disappear when answered No . If the individual does have a diagnosis MNCD, then the following questions are required and should be completed to support the primary mental illness diagnosis. 16. Section E. Level One Screening Criteria for Intellectual Disability or Related Condition If Yes , does the individual have a Mild, Moderate, Severe, Profound, or Unspecified Intellectual Disability Related Conditions are not listed in this field 17.

7 Section E. Level One Screening Criteria for Intellectual Disability or Related Condition Does the individual have a diagnosis or history of a Related Condition? If No is indicated questions 2b thru 2d will disappear. If Yes is indicated, choose the diagnosis and provide the age of onset in the blank. If the diagnosis is not listed, click on Other Related Condition to type the diagnosis Mental Illness is not considered a Related Condition . 18. Section E. Level One Screening Criteria for Intellectual Disability or Related Condition Did the Other Related Condition develop before age 22? (Review the diagnosis and age of onset checked from question 2A). If No is indicated questions 2C and 2D will disappear. If Yes or Unknown is indicated, please answer questions 2C and 2D (see next slides). 19. Section E. Level One Screening Criteria for Intellectual Disability or Related Condition 20.

8 Section E. Level One Screening Criteria for Intellectual Disability or Related Condition Results in substantial functional limitations in three or more major life activities? Reminder: The functional limitation must have impacted the individual prior to the age of 22. A Level 2 Screening would be indicated if the individual has a related condition prior to the age of 22. and 3 or more functional limitations. To assist with answering the questions in Section E, the submitter might have to ask the individual, guardian, or other sources as to whether or not the individual was receiving Developmental Disability Services (DD DMH) in the community. 21. Section F. Special admission Category A Special admission Category (SAC) is only utilized if a individual triggers a Level 2 Screening . The submitter does not have to choose a SAC for processing. SAC numbers 1 thru 5 must be preapproved by COMRU prior to admitting to SNF.

9 Failure to preapprove these SACs may result in loss of Medicaid payment. 22. Section F. Special admission Category The submitter will be able to view the determination of the SAC by logging back into the application (using the unique Return code). When SAC #3 or #5 is approved, it is the responsibility of the skilled Nursing Facility to subsequently notify COMRU via email if the individual will exceed the thirty-day special admission stay. In order to avoid loss of Medicaid payment, notice must be made to COMRU within the first 14-20 days of the individual's stay to allow time for the processing of the Level 2 Screening . If the individual discharges, transfers, or leaves the Nursing Facility for any reason the SAC is considered completed and a new application request will need to be submitted to COMRU prior to the individual's return to any Nursing Facility . 23. Section G.

10 Physician Signature Once the Level 1 form has been completed, it is then sent to the Physician for their signature. The submitter will need to scroll down to the end of the application and click the Save and Return Later. button. 24. Section G. Physician Signature The submitter will receive a Return Code. IMPORTANT: Make sure to write the code down as the submitter will need this code to send to the physician. The submitter will utilize this Return Code throughout the process. The code is able to be copied and pasted into a computer document if needed. (Using the mouse highlight the Return Code and right click, then click on the copy option) 25. Section G. Physician Signature When emailing the physician, it can be completed 2 ways: 1. When the screen appears, enter the email address and click survey link. A second personal email will need to be sent from the submitter to the physician with the Return Code so they are able to access the application.